Can Strattera (atomoxetine) be used to treat anxiety and depression?

Strattera (Atomoxetine) for Anxiety and Depression

Strattera (atomoxetine) is not FDA-approved for treating anxiety or depression as primary conditions, though it may help with anxiety symptoms in patients who have ADHD with comorbid anxiety disorders. 1

Mechanism and Indications

• Atomoxetine is a selective norepinephrine reuptake inhibitor (not classified as a stimulant) primarily indicated for the treatment of ADHD 2
• It works by selectively inhibiting presynaptic norepinephrine reuptake in the prefrontal cortex, with high affinity for norepinephrine transporters 2
• Unlike antidepressants such as SSRIs or SNRIs, atomoxetine is not FDA-approved specifically for anxiety or depression treatment 1

Evidence for Anxiety Treatment

• Clinical trials have demonstrated that atomoxetine does not worsen anxiety in patients with ADHD and comorbid anxiety disorders 1
• In a 12-week double-blind placebo-controlled trial of children and adolescents with ADHD and comorbid anxiety disorders (separation anxiety, generalized anxiety, or social phobia), atomoxetine did not worsen anxiety as measured by the Pediatric Anxiety Rating Scale 1
• In a 16-week trial of adults with ADHD and social anxiety disorder, atomoxetine did not worsen anxiety symptoms 1
• One open-label study showed atomoxetine may be beneficial as an adjunctive treatment for adults with ADHD and partially responsive anxiety symptoms who were already on SSRIs or SNRIs 3

Evidence for Depression Treatment

• Limited evidence exists for atomoxetine's efficacy in treating depression as a primary condition
• In a study examining atomoxetine alone or combined with fluoxetine for ADHD with comorbid depression or anxiety, both treatment groups showed improvement in depressive symptoms, but the study lacked a placebo-only arm to determine if atomoxetine specifically caused these improvements 4
• Atomoxetine may be indicated for ADHD with comorbid depression, but not as a first-line treatment for depression itself 5

Comparison with Established Treatments for Anxiety and Depression

• For depression and anxiety disorders, second-generation antidepressants (SSRIs and SNRIs) remain the first-line pharmacological treatments 6
• SSRIs like sertraline have demonstrated efficacy in both depression and anxiety disorders with favorable tolerability profiles 7
• Duloxetine and venlafaxine (SNRIs) have shown consistent efficacy in treating depression and anxiety disorders 6

Safety Considerations

• Common adverse effects of atomoxetine include headache, abdominal pain, decreased appetite, vomiting, somnolence, and nausea 2
• Serious adverse effects may include:
  • Increased vascular tone (slight increases in heart rate and blood pressure) 2, 5
  • Decreased growth rate in children 5
  • Increased risk of suicidal ideation (carries a black box warning in the US) 2, 5
  • Potential for rare liver injury 2

Clinical Decision Algorithm

1. For primary anxiety or depression:

   • First consider FDA-approved treatments: SSRIs (like sertraline) or SNRIs (like duloxetine or venlafaxine) 6
   • These medications have established efficacy for both conditions with well-documented safety profiles 6

2. For patients with ADHD and comorbid anxiety or depression:

   • Consider atomoxetine as a treatment option for the ADHD, which may also help with the comorbid conditions 1, 5
   • For more severe depression symptoms, combination therapy may be needed (e.g., atomoxetine plus an SSRI), though this should be monitored carefully 4

3. For treatment-resistant cases:

   • Atomoxetine may be considered as an adjunctive treatment to SSRIs or SNRIs in adults with ADHD and partially responsive anxiety 3
   • Close monitoring for potential drug interactions and side effects is essential 1

Important Caveats

• When combining atomoxetine with serotonergic medications (like SSRIs), monitor for signs of serotonin syndrome, especially during the first 24-48 hours after dosage changes 6
• Atomoxetine is not a controlled substance and has negligible risk of abuse, which may be advantageous for certain patients 2
• Cardiovascular monitoring is recommended due to potential increases in heart rate and blood pressure 2